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-------- --- --- .__.-...L-.. .�-- - --- -----—_�'-,S-_0 APPLICATION FOR 'j'd�,�.ATION PERMIT Permit No. ...`.'�-U _. ---- ---- ------------------ (Complete in Dupiicate) ............. This Permit Expires i Year From Date Issued Date issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the�rKeroeinclescrile�. This application is made in compliance with County Ordinance No. 549, JOB ADDRESS AND LOCAT ------ - y F ,. YL Owner's Name-------------------_ r -�J---- -- ----- - --- -- `- ---- ----- -------------- ---------------------- Phone--•-•---- --•----------- ......... Address_... � 3y 3 ;>7I r Contractor's Name__________ _ -sem Installation will serve: Residence ❑ Apartment House ❑ Commercial Trailer Court ❑ Motel ❑ Other ❑ k qq Number of living units: _ _ Number of bedzrooms -- Number of baths Vii._ Lot size__ /'---'________________________________ Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table tt. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeHardpan ❑ Previous Application Made: (If yes,date------_- _-_- ) No New Construction: Yes gg-11–o ❑ FHA/VA: Yes ❑ No e—, TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public ewer is available within 200 feet.) �� I Septic Tank: Distance from nearest well---'_��_i�-----Distance from foundation__.ZO---------Material/r 140-iF/I----------------- � No. of compartments----v----- -------/_Size-_X169-------------Liquid de`th__y_-._-_.._..______CapacityZY–e-:�____ p - _____..__Distance to nearest lot line_��__..__. Dis osal Field: Distance from nearest well_, ___._Distance from foundation_ gg ; Number of lines------,------x.�.j----- _Length of each line___ __ ___� Width of trench-G___.___ ' Type of filter materia //a p � '�` f'� __. __�_De Depth of filter material-._��__-__f_Total length--- - =___._/__--___---'__ w Seepage Pit: Distance to neareell_- L%gC ...---Distance frQrn foundation__y� _____.Distance to nearestFor}e_ .�____.._ Number of pits______________________Lining materialSize: Diamete r_. _...__..----Depth_ Cesspool: Distance from nearest well_________________Distance from foundation................... g ---...,Linin material---1-------------------------------El Size: Diameter-------------------------- ----- - -- Depth----------------------------- ---------------------Liquid Capacity--.-------------------------gals. Privy: Distance from nearest well-----______----------------------- ------___----_Distance from nearest building--------------.____-________-._____-.-_. 0 Distance to nearest lot line--- - -------------- ------ n � ------•-'--°-�-----�-r--t--.r-�- ---_-----------=--I-E-!-�-�-- ------_--�------ --r--_ --fi---7--e--'-o--- ----f---------r--- -----'-�--- Remode4iand or airing Id crihe------- --- .--s- - 'o f! ----------------------•---------------------------------------------------------------------- --...tx ------------------------------------ ----------------------------------------------------------------------•------------------------------------------------------------------------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of. he San Joaquin Local Health District. (Signed)---------- fes" � i/! ------------------------------ r Contractor) By:--••------------------------------------------- ------------------------- -- -- =--------------(Title) " (Plot plan, showing size of lot, location of system in re) ion to wells, buildings, etc., can be placed on'reverse side). FOR DEPARTMENT USE ONLY p ff APPLICATION ACCEPTED BY DATE ll REVIEWEDBY---------------------------- --------- ---- --------- ------------------------ ------ DATE-------- -------------------------------------------------- BUILDING PERMIT ISSUED-------------------------------------- ---------- ----------*•------------------- ------ DATE ; Alterations and/or recommendations:----L�..e-_ ._.lr_,--- _t ------ jnt'` =.F- - -------ly r_.--- - '_--_`y - ----ef!� ------- -------------------------------- ------------------------------------ --------------------•---------------- ---------------------------------- - ---------- ---------------------------------------------------------------------------------------------------------------- ------------------------ -------•---------------------------- --------------------------------- ------------------------ -----------------•--••--•---------------•-------------------------------------------------------------------------------- FINAL INSPECTION BY:------`��.----- ----------- Date------ r� �/ ............. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.0 O.